— 生理適應 · MEDIUM · MCQ —
護理師正在照護一位鐮狀細胞危象（sickle cell crisis）病人。哪項評估發現最能指示血管阻塞（vaso-occlusion）？
A nurse is caring for a client with sickle cell crisis. Which assessment finding is most indicative of vaso-occlusion?
- AHemoglobin level of 7.0 g/dL血紅素濃度 7.0 g/dL
- BSevere, localized pain✓ 正解嚴重且局部的疼痛
- CJaundice黃疸
- DPositive direct Coombs test直接 Coombs 試驗陽性
— Explanation · 中文詳解 —
鐮狀細胞危象（vaso-occlusive crisis）是因紅血球變形阻塞小血管，導致組織缺血缺氧，引起劇烈疼痛。這種疼痛通常是嚴重的、局部的，且與阻塞部位相關。血紅素低、Coombs 陽性、黃疸是其他症狀，但嚴重的局部疼痛最直接反映血管阻塞的機制。
For a client with burns on the chest and abdomen, checking for airway patency is the highest priority assessment to rule out inhalation injury, which is the most immediate threat to life.
✦ 台美臨床差異
美國的血栓疾病照護有專門的治療指引，強調早期止痛與水化；台灣的照護也相似，但病人對疼痛的忍受度與求助意願可能因文化因素而影響處置時機。